2014_0908 C�ISCK ONE:
IRR.IGATION ./ DOMESTIC FIRELINE
BAC'I�ZOW PREVENTION ASSEIV�LY TEST AND MAIIVZ'ENANCE REPORT
NAME OF PWS: �TA��� -�—S� C�m P I�
PWS I.D.#
LOCATION OF SERVICE: �'`V� t�f?
The bacl�low preveation asscmbly decailod below has beea tesud aad m �n ain� � nquired b�, 'ITVRCC
re¢uladons aad is cerd5ed to ba operating withia acccptable paramcters.
TYPE OF ASSEMBLY
� Reduced Pressurc Principle o Pressure Vacuum Breaker
� Double Chxk Valvc o Amtosphere Vacuum Breaker
Manufactiaer �'e� �U Size /�
Model Ivumber � �' � Located At �r faf1� ��S �
Serial N�ber � ��?�
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Double Check Vaive Assembly
lst Check 2 r� �nd Checi: '2,� �ef Vatvt �►ir Inlet Check Valve
InitiaI Test DC-Closed Closed Ti�ht h� Opeae�at Opeaed at _osid
Ti�ht � Leal:ed o psid __�osid
QQ�� RP-__psid
\ Leal:ed 0 Did not Opca o Leake� o
�P�
aad
Materials
Used
Test Afttr DC-Closed Closed Tight o ppened at Opmed at __nsid
Repair Tight ❑ �sid _osid
RP sid
The above is ccztified to be true.
�
Firm Name � �S�• Certified Teste 1 U !
a i � DGY�6`� n� g'
Firm Addrass I � � �1� Cat Tester No.
Gauge # ��'-�' $OC�C�
llate last accuracy tested � � � ��
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy